Interdisciplinary topics in gerontology最新文献

Cancer in elderly patients is becoming a global issue, with the aging of the population and increased incidence of cancer with aging. Older patients with cancer have unique needs that can best be addressed by the integration of geriatrics principles and oncology care. Unfortunately, the worsening shortage of oncologists and geriatricians makes the care of the older patient with cancer increasingly challenging. Practical issues to consider when creating a geriatrics/oncology partnership include the available resources in terms of interdisciplinary team members, the patient population in need, and the ability to provide primary, consultative, and/or shared care. Ultimately, creative strategies will be needed to maximize the limited availability of the geriatrician and oncologist.

Cancer vaccination is less effective at old than at young age, due to T cell unresponsiveness. This is caused by various age-related changes of the immune system, such as lack of naïve T cells, defects in activation pathways of T cells and antigen-presenting cells, and age-related changes in the tumor microenvironment. Natural killer, natural killer T cells, and γδT cells of the innate immune system also change with age but these responses may be more susceptible for improvement than adaptive immune responses at older age. This chapter compares various studies involving adaptive and innate immune responses in elderly and cancer patients, as well as cancer vaccination at young and old age. Finally, potential new directions in cancer vaccination at older age are discussed.

Geriatric oncology nursing is a specialization that requires unique knowledge and education to care for the older person diagnosed with cancer. Understanding principles of functioning in a multidisciplinary team setting, assessment of an older patient, and cancer-related issues are central elements of the role of the geriatric oncology nurse. Additionally, education of patients and families are important in helping the older person navigate the healthcare system. The purpose of this chapter is to review the current literature in geriatric oncology nursing.

The construct of frailty is germane to that of aging, but a clinical definition of frailty is still wanted. In the geriatric literature, frailty has been conceived in two different ways. The first one is a threshold beyond which the functional reserve of a person is critically reduced and the tolerance of stress negligible. The second is as a progressive reduction of functional reserve due to a progressive accumulation of deficit. In this construct it may be hard to distinguish frailty from aging. Neither concept has at present a clear application in the management of older cancer patients. Studies are needed to establish whether the construct of frailty proposed by Fried et al. may be predictive of decreased cancer-independent survival and of decreased treatment tolerance in older cancer patients.

Older adults are at high risk for functional decline after a cancer diagnosis. Physiologic changes of aging which negatively impact body composition, strength, and fitness increase vulnerability to the development of short- and long-term disability when stressed with cancer burden and treatments. Treatment-associated physical disability impairs quality of life, limits therapeutic options, and contributes to the social and economic burden of cancer care in the elderly. Despite this, few clinical trials capture disability as an outcome or focus on whether it can be ameliorated in this population. Exercise has multiple positive effects on physical health and well-being in non-cancer elderly populations and holds promise as a supportive care intervention to improve physical function and symptoms during and after cancer treatments. The majority of studies supporting the positive benefits of exercise among cancer survivors have been performed in younger patients. Results from limited elderly-specific trials suggest that physical activity interventions are safe and effective in older cancer survivors, with prostate cancer survivors representing the best studied cohort of older persons with cancer. Many questions remain unanswered with respect to optimal timing, mode, intensity, and delivery of exercise interventions for older patients. While available data support the potential benefit of exercise for elders with cancer, recommendations will need to be individualized to optimize participation, safety, and efficacy.

The incidence of cancer will increase dramatically among elderly people in the 21st century. The first French National Cancer Plan (2003-2006) with the French Ministry of Health supported the creation of 15 pilot coordination units in oncogeriatrics (UPCOG) in 13 out of the 27 French regions. The second French National Cancer Plan (2009-2013) continues to support oncogeriatrics. Based on evaluation of the pilot experiment in 2010, requirement specifications for an oncogeriatric coordination unit were defined and rolled out nationwide. The following missions were set out: to adjust cancer treatment in elderly people and enable all elderly cancer patients to benefit from this oncogeriatric approach; to stimulate specific research in oncogeriatrics; to promote training of health professionals, and to promote information. The clinical use of a geriatric prescreening tool as a routine procedure needs to become more widespread. Lastly, recommendations for treatment strategies tailored to elderly persons with high-incidence cancer must be developed. Fifteen oncogeriatrics coordination units were founded since 2011, covering 11 regions. Roll-out continues in 2012.

The elderly comprise the majority of patients with cancer and are the recipients of the greatest amount of chemotherapy. Unfortunately, there is a lack of data to make evidence-based decisions with regard to chemotherapy. This is due to the minimal participation of older patients in clinical trials and that trials have not systematically evaluated chemotherapy. This chapter reviews the available information with regard to chemotherapy and aging. Due to the lack of prospective data, the conclusions and recommendations made are a consensus of the available information. Extrapolation of data from younger to older patients is necessary, particularly to those patients older than 80 years, for which data is almost entirely lacking. The classes of drugs reviewed include alkylators, antimetabolites, platinum compounds, anthracyclines, taxanes, purine analogues, antimicrotubule agents, camptothecins, and epipodophyllotoxins. Clinical trials need to incorporate an analysis of chemotherapy in terms of the pharmacokinetic and pharmacodynamic effects of aging. In addition, data already accumulated need to be re-analyzed by age to aid in the management of the older cancer patient.

The incidence of cancer increases with advanced age and the majority of cancer deaths are in patients aged ≥ 65. The geriatric population is a heterogeneous group and a patient's chronologic age does not always correlate with underlying physiologic status. Oncologists need to be able to obtain information on physiologic and functional capacity in older patients in order to provide safe and effective treatment recommendations. The Comprehensive Geriatric Assessment (CGA) is a compilation of validated tools that predict morbidity and mortality in community-dwelling older adults. The various components of the CGA have also been shown to influence clinical decision-making and predict outcomes in older cancer patients. The combined data from the CGA can be used to stratify patients into risk categories to better predict their tolerance to treatment and risk for chemotherapy toxicity. However, the CGA is a comprehensive tool requiring significant time and training to perform. A variety of screening tools have been developed which may be useful in the general oncology practice setting to identify patients that may benefit from further testing and intervention. This chapter will review the components and predictive value of CGA in older cancer patients, with emphasis on how CGA can practically be incorporated into clinical practice.

Cancer and aging appear to be inexorably linked, yet approaches to ameliorate them in concert are lacking. Although not (easily) feasible in humans, years of preclinical research show that diet and growth factor restriction each successfully address cancer and aging together. Chronic treatment of genetically heterogeneous mice with an enteric formulation of rapamycin (eRapa) extended maximum lifespan of both genders when started in mid or late life. In part, cancer amelioration in treated mice suggested that long-term eRapa, like diet restriction, could be a pharmacological approach feasible for use in the clinic. We review the current understanding of the role of the mechanistic target of rapamycin (mTOR) in cancer and aging. We also discuss the tumor immune surveillance system, and the need for a better understanding of its responses to mTOR inhibitors. We also address the issue of the misperception that rapamycin is a potent immunosuppressant. Finally, we review the current state of mTOR inhibitors in the cancer clinic. Because of the burgeoning elderly population most at risk for cancer, there is a great need for our eRapa findings to be a proof of concept for the development of new and more comprehensive approaches to cancer prevention that are safe and also mitigate other deleterious effects of aging.

The incidence and prevalence of most cancers increase with age. The immune system is a unique mechanism of defense against pathogens and possibly cancers, however there is a body of evidence that the immune system of the aged is eroded, a phenomenon termed immunosenescence. Each arm of the immune system, innate and adaptive, is altered with aging, contributing to increased tumorigenesis. Related to immunosenescence, a low-grade inflammation also develops with aging contributing also to increase carcinogenesis. Understanding the contribution of immunosenescence to cancer development and progression may lead to better interventions in the elderly.